Ep48: Training in the Bush Part 1—Country NSW

Ep48: Training in the Bush Part 1—Country NSW
3 July 2019

Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

A third of Australia's population is classified as regional or remote, but since it's such a big place it's hard to provide comprehensive heath care all over. As a result, chronic disease gets treated later and mortality is 1.3 time higher than it is in major cities, according to the Australian Institute of Health and Welfare.

There are only 42 percent as many specialists per 100,000 population in regional areas as there are in major cities, but research shows that these experiences are more likely to lead to permanent careers in the country.

In this episode we visit the country town of Dubbo about 6 hours drive northwest of Sydney. The base hospital services a catchment of 130,000 people spread across an area the size of Great Britain. While need in this area is high, Dubbo presents an example of strong clinical leadership and training across many specialties.


Dr Florian Honeyball FRACP (Dubbo Base Hospital, University of Sydney)
Dr James Collett FRACP (Dubbo Base Hospital, University of Sydney)
Dr Joel Riley (Dubbo Base Hospital, University of Sydney)

Written and produced by Mic Cavazzini. Music licensed from FreeMusicArchive; 'Fervent', 'Cast in Wicker' by Blue Dot Sessions, 'Hypocritopotamus' by Doctor Turtle, 'Slow Burn' by Kevin McLeod. Image courtesy of The Land.
Editorial feedback for this episode was provided by members of the RACP's Podcast Editorial Group; Alan Ngo, Stella Sarlos, Paul Jauncey, Lisa Mounsey, Michael Herd, Atif Slim, Rhiannon Mellor, Seema Radhakrishnan, Leah Krischock, Angela Chen, Genevieve Yates, Adrienne Torda, Philip Gaughwin, Andrea Knox.


Useful Links
Online Learning Resources@RACP
eLearning course on Telesupervision

BroomeDocs podcast
Specialist Training Program [The Department of Health]
Basic Physician Training [Budhima Nanayakkara]
Support for Rural Specialists Australia
SRSA eLearning Resources
Rural Health Continuing Education program
Continuing professional development for rural health professionals [Health.Vic]
Supervisor Support and Resources [RACP]
Accreditation Renewal – Training Provider Standards [RACP]


MIC CAVAZZINI: Dubbo is a country town about 6 hours drive northwest of Sydney, past the scenic Blue Mountains, past the race-track at Bathurst and past the wineries of Orange. If Dubbo is known for anything, it’s the savannah-like Western Plains Zoo, but the hospital has traditionally been known as a perfunctory and unglamorous rotation for interns and trainees.

The last time I was at Dubbo Base Hospital was 1986. I was six years old and had a humerus fracture after falling from a tree on an outlying farm. Being a Sunday, my arm was put in a cast by the on-call obstetrician. A couple of months later my dad took me to see an orthopod in Sydney – who kindly offered to break it again and set it properly.

Instead, Dad took me to a computer arcade at Pier One to cheer me up. That was long ago redeveloped into a 5 star hotel, but I was expecting to find Dubbo Base unchanged from the squat red-brick pile from my childhood. How wrong I was. I found that not only is the hospital going through a massive renovation, but that the physicians there were engaged in building a top-spec model of care and workplace culture.

In today’s podcast we’re going to talk about what it’s like to train as a specialist in the country. In the next episode we’ll hear from far-off Broome. Welcome to Pomegranate Health. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.

A third of Australia’s population is classified as regional or remote , but as it’s such a big place it’s hard to provide comprehensive heath care all over. As a result, chronic disease gets treated later and mortality is 1.3 time higher than it is in major cities, according to the Australian Institute of Health and Welfare.

Although GP coverage in regional areas isn’t bad, there are 42 percent as many specialists per 100,000 population as there are in major cities, and in remote areas it’s more like 11 percent. Only 15 percent of specialists even undertake training in rural areas but research shows that these experiences are more likely to lead to permanent careers in the country.

Let’s talk about Dubbo. It’s has a population of about 40,000 people, and the hospital services a catchment of another 90,000 spread across an area the size of Great Britain, much of it wheat fields and grazing land. In the role its secondary service plays for a widely dispersed population, Dubbo can be compared to other regional centres like Tamworth or Mackay or Mildura.

FLORIAN HONEYBALL:   In terms of the picture of what Dubbo’s like, so, Dubbo is a town of 40,000.  We have a rural referral hospital here, which services 23 smaller hospital across the majority of Western New South Wales.  Each of those smaller hospitals is run by GPs, and they do a really good job, the rural generalists out here, to the degree that half of them might be happy to have on the general medical roster here …

MIC CAVAZZINI:               That’s consultant oncologist Dr Florian Honeyball. He first rotated to Dubbo as an intern, then in 2011 took up an advanced training position under the Specialist Training Program. This is a Commonwelath program to fund registrar positions not just in rural areas, but also neglected metropolitan settings outside the teaching hospitals; areas like aged care, private rehab facilities, community and aboriginal health.

The STP now funds over 1000 posts across the country, and 345 of these are managed by the RACP. Of these, a third cover Basic Training, General Medicine and General Paediatrics. There are about 30 posts each in the fields of geriatrics, rehab medicine, palliative medicine and in public health, but most other specialties are represented too. Dr Honeyball explains how the STP position for oncology was created in Dubbo to address the above average cancer mortality in Western NSW.

FLORIAN HONEYBALL:   Yeah, so, look, to tap into that, the reason why there’s high mortality, I think, is twofold:  number 1, people aren’t getting diagnosed early enough. A host of different reasons, primary health care, poorer health literacy.  So there’s that aspect to it, and then secondly, it’s the access to investigations and secondary-level care such as oncology, medical oncology, radiation oncology, and treatments associated with that, and prior to me coming here, it was entirely staff by fly-in fly-out oncologists from Sydney one day a week, and so the service provided was at its limits.  We were seeing about 190 new patients per year, when the numbers kind of suggested we should be seeing closer towards 400 or 450, so we thought there was a lot of unmet need. 

What we found after I started working here is that number all of a sudden skyrocketed from 190 to 379, which is close to where we thought the numbers should be, but even still, looking at the postcodes of where people were coming from, there still was over-representation close to Dubbo and not enough people with postcodes of, you know, Brewarrina, Bourke, which is 400 kilometres from Dubbo but still part of our catchment.  Most of us do outreach, it’s just expected as part of providing a service out here because we know that if we don’t provide an outreach service, even if we offer video conferencing, we don’t have the same sort of uptake.  So the majority of us would do several outreach clinics a month.  I myself, I’ve done two this week—

MIC CAVAZZINI:               Just got back from Mudgee half an hour ago.

FLORIAN HONEYBALL:   I just got back from Mudgee, yes, it was a bit of a schlep to get back here in time.  So Mudgee is our largest drainage town.  It has a population of 11,000  and again, a lot of visiting services but no resident specialist service in town.

MIC CAVAZZINI:               So the GP will know that you’re in on the second Tuesday of every month.

FLORIAN HONEYBALL:   Yes. So we generally try to provide a weekly service to Mudgee in oncology, between me and my colleague, Dr Rai, and the GPs know where our rooms are, and when they do their rounds, they’ll generally pop upstairs if they’ve got a question to ask. And that’s the nice thing with smaller hospitals, is that, yeah, you’re the big fish in a small pond, but it does mean that there’s a lot more continuity of care, I think, and I know all the – I know most of the GPS in the district, and they all know me, and so if there’s a question, we’ll know how to ask each other.

MIC CAVAZZINI: For the health geography nerds out there, Dubbo is an island in a sea of Modified Monash 5. If you keep driving west, it become classification six within an hour, and then after another two hours you’re in very remote terrain until you hit Alice Springs.

Despite the high needs of the large Dubbo catchment and its relative remoteness, it has been historically been neglected compared to country towns further east. But all that is changing. The hospital is now a giant construction site, after Dubbo Base received 250 million dollars in state and federal funding.

The specialist services here used to depend on a combination of visiting medical officers and fly in-fly out clinicians. VMOs might have a contract of a few weeks or months, while FIFOs will spend a day or two on site on each trip. But Dubbo has been steadily building a community of locally-based specialists. James Collet and Joel Riley explain why this is important for continuity of care for country-based patients.

JAMES COLLETT:               I’m James Collett, I’m a general physician and nephrologist out in Dubbo.  I first came out  here in 2011 as a rotating basic trainee, and then completed by renal training up in Darwin, and then came back here and started work here.

JOEL RILEY:         I’m Joel Riley.  I’m a fourth-year advanced trainee, doing dual training in general medicine and rheumatology.  Apart from that, I’m a father of two kids, left back for the South Dubbo Wanderers–

MIC CAVAZZINI:               How’s the season going?

JOEL RILEY:         We’re fifth.  Thank you for asking. But, you know, the only thing to do after a setback is come back.

MIC CAVAZZINI: That’s the football or the training?

JOEL RILEY:         The football.  Yeah, the – let’s not talk about the training.  I came out here as a second-term BPT rotating in 2014 and loved it so much that I elected to come back in 2015, again, at the end, and now I’m back here doing a year of – six months of acute medicine, which will complete my training.

MIC CAVAZZINI:               Alright – what’s your week or your month pan out like in terms of your time spent in Dubbo, in private clinics, and then more remote outreach?

JAMES COLLETT:               So at a consultant level, you know, a lot of the way Dubbo works in that it is quite unique here and that it’s predominantly a staff specialist model, as opposed to VMO models.  So most of the general physicians are on staff here, and so don’t do a lot of private medicine.  There is scope for private work in various specialties, and there are fly-in fly-out people from Sydney that come and do gastroenterology and some rheumatology and things like that, but often they expect patients to do things back in Sydney not understanding how the service work in Dubbo.

Again, I think to properly service an area, you need Dubbo to be the centre of providing that healthcare, not Sydney, and then you do your outpatient clinics, which again are Medicare-funded public clinics. And on top of that, you usually do some outreach.  So I go to Bourke and Mudgee for outreach clinics about three out of five weeks.  We also have a very good tele-health service, so if we need to see them more urgently or need to closely follow them up, again, there’s Medicare billing items for that, and it all works very smoothly.

And our month is usually if we’re on call for general medicine, we’re on call for that month.  That alternates, so month on month off with another physician, and the general medicine actually is something that, although scary at first, is probably one of the most appealing part of the job, and I also do some stuff with Sydney University because there’s a school of rural health here.

JOEL RILEY:         Yeah, I could have, if I chose to forego general medical training, I probably would never have to think about acute gastrointestinal bleed ever again because if my patient had one, I would call the relevant specialist, and that’s the end of thinking about it. At times you’re the one on the spot who has to do the thing to get the patient through the next 24/48 hours until you can call for help. And  there’s a lot of satisfaction to be had, I think, in maintaining those general medical skills that you work so hard to develop in the first place through your training.

MIC CAVAZZINI:               What about in your specialties in nephrology and rheumatology?  What sort of diagnostic of treatment tools are you missing, and is it …

JAMES COLLETT:               Like everywhere, and Dubbo probably reflects this, things have become more sub-specialised, and, you know, yeah, there are holes in some of the services, but we’re getting a hospital-based MRI that’s going to be Medicare-funded.  We’re getting a big cancer centre.  In terms of nephrology services, we’re again at a unique position because there’s three nephrologists in Dubbo.  We can do biopsies, we can do access, complicated access usually has to go to Sydney, and we obviously don’t do …

JOEL RILEY:         Access for dialysis.

JAMES COLLETT:               Access for dialysis, sorry, and obviously we don’t do kidney transplants and we never will, but we manage very complex transplant patients in the community here, and so really, there’s not a lot that we don’t offer that aren’t offered in the bigger centres.

JOEL RILEY:         In terms of rheumatology, I know – a shout-out to any rheumatologists or general physicians listening who have shared the pain of trying to get a temporal artery biopsy done in a major metropolitan centre, which can be, depending on the centre quite fraught.  Dubbo has to rank up there with the most efficient in getting a temporal artery biopsy of anywhere I’ve ever worked.  There’s good relationships between all the clinicians and the surgeons, and they understand the importance of this non-urgent procedure, and so it gets done.  Similarly, muscle biopsies get done, and in terms of actual diagnostics, really, the only thing we’re missing is dual energy CT for crystal disease, but I mean, that’s a software package, and it’s just a matter of talking to the radiologist. And PET scanning, which has an increasing role in rheumatology but is yet to be Medicare-funded.

MIC CAVAZZINI:               Anyway, yeah

JOEL RILEY:         So that’s still emerging, but with the new cancer centre going in, we will have a PET scanner physically in Dubbo, and should things end up getting funded, say, in vasculitis, you know, the hardware will be here ready to go.

MIC CAVAZZINI:               And is that – that sounds like quite a comprehensive coverage.  Is that representative of, you know, Mildura or Rock–

JOEL RILEY:         No.

JAMES COLLETT:               No, I think it’s a pretty unique model.

JOEL RILEY:         I sit on the Regional Rheumatology Committee of the Australian Rheumatology Association, and I get a spreadsheet of, you know, what service is available where, and the number of actually regionally-based, not even distinguishing between VMO, private, or staff specialist, but actually regionally-based rheumatologists is very very small. Now that’s not to disparage the people in the cities because a lot of them provide excellent outreach services, but I think our patients do prefer to see somebody who’s local.  I think that treatment close to home by somebody who’s from your community is qualitatively different.

MIC CAVAZZINI:               So, again, Dubbo would be exceptional in being so well-resourced compared to –

JOEL RILEY:         Exceptional is the word for Dubbo. In that in the half a dozen or so rural hospitals I’ve worked in, Dubbo is the exception in terms of the model and also in terms of the vision for where the hospital’s heading.

MIC CAVAZZINI:               Part-time staffing is a necessary reality for most regional hospitals but it can make for a weaker workplace culture. Florian Honeyball says that when he first rotated to Dubbo as an intern, there wasn’t a very strong leadership. The training was seen as pretty ordinary, and most trainees put the hospital last on their preference list. You clocked in, you went home to sleep, and waited it out til your service term was done.

The vibe at Dubbo Base began to change with the arrival of two physicians from abroad. When Dr Jennifer Fiore-Chapman applied to a consultant position in 2008, the hospital managers were thrilled when she asked if there was also a place for her partner Colin McClintock, also a nephrologist. They have became passionate advocates for building permanent services and personnel in their region, and about maintaining a succession plan for high-quality training.

The Dubbo model counters many of the stereotypes about rural medicine—that supervision is poor—that you’re always on-call, and that at any minute could be thrown in the deep end outside your scope of practice. In Joel Riley’s experience at a bunch of country hospitals, this picture is a throwback to the past or perhaps to tv drama.

JOEL RILEY:         So it’d be lying to say that the clinical medicine doesn’t have a different set of demands.  There is a different set of demands placed on you as a clinician, but we’re all in the same boat, and ultimately, the patients are the ones in the deep end. But I think most people welcome the opportunity to gain rural experience and get a lot more independence and exposed to a lot more, sadly, a lot more pathology out here, and stuff in advanced stages.  I mean, the intensivists who visit out here are often telling me that they see stuff here that they never see anywhere else, and in my experience, only the Northern Territory really compares in terms of complexity and severity of clinical presentations.  You know, it staggers me why people don’t go where the disease is.  You know, if you go where the disease is, you have more opportunity to, you know, rack up the QALYs, add quality of life.

MIC CAVAZZINI:               And the supervision is just a phone call away?

JOEL RILEY:         Always.  I mean, it depends on the culture of your place, but speaking about the culture of Dubbo, I’ve never felt under-supported in this hospital. And if you’re sitting at home listening to the podcast, being worried that, you know, you’ll be out of your depth, you’re probably the person who needs to be out here providing the service to the patients, you know, get amongst it, and we’re linked with RPA as our basic training network, and often we end up getting people who unfortunately have not managed to pass the clinical first time around.  They come out here, and they are absolutely swamped with opportunities to do very complex long cases with patients who are very glad to do them.  So I remember back in the day, I had a patient self-discharge because they’d been seen for too many short cases.  It doesn’t happen out here.  There’s not the sort of infestation of doctors that you get in metropolitan centres.

JAMES COLLETT:               And as Joel said there’s less places to hide in rural places.  You actually – things that might get lost in Sydney in a big hospital, people pick up that you might be deficient in an area, and that’s actually good for your training, when people can notify you about that and say, actually, you need to get better at that. And the registrars actually get a lot more independence.  They’re well supervised, but the level of their responsibility is much higher here, and registrars often crave that because they’re swamped in Sydney by layers of hierarchy, whereas here it just doesn’t exist.  So that’s the reason I was really keen to come out here, and the culture is certainly one of just helping each other, and so even though we’re all busy, and yeah, it can get frustrating when patient care is compromised because of lack of access to certain services, but we work around it and do the best we can, and that’s actually part of – the enjoyable part of the job is trying to be advocates for these patients.

FLORIAN HONEYBALL:   Absolutely, yeah, and, look, the other thing I’ve learned since being out here is you really have to step up.  So general practitioners step up a lot, but also, in medical oncology, so, you know, I saw 379 new patients in a year—that gave me an incredible amount of experience. And I really do feel that I am a much more experienced oncologist as a fifth-year consultant than a lot of my peers would be, without trying to sound too arrogant, but just purely based on the numbers of people that I see, and I think it’s the same thing you would get from an STP training position in that you – just the breadth of disease and patients that you see, I think, will make you a more rounded clinician.

MIC CAVAZZINI:               It’s one of the truisms that Australia’s a big place, and regional areas often have resource limitations. But one of the positives that people try and spin on training in a rural area is that you’re given more independence and more responsibility and that you can learn really real diagnostic problem solving. Would you be able to relate to that?

FLORIAN HONEYBALL:   I think also trying to manage people in a different environment is actually challenging, so someone lives 400 kilometres away from Dubbo, it is difficult to convince them to come into town for a CT scan to monitor their disease progress every three months, so sometimes I just have to make do with guesswork and old-school palpation. Not being able to just say to someone, “Can you pop back in, I’m a bit worried about your blood test.  I just want to have a look at it and see how you are”.  Instead, you have to devise a new stratagem to work out, okay, well, who can I rely on in this patient’s community 300 kilometres away to be able to make sure they’re – that they can be properly assessed?  Can I use tele-health, can I use a general practitioner or a rural nurse in that community to convey what I want done? 

So they’re different challenges, and I think you have to be able to problem solve and we’re starting to try to use some models that we’re seeing elsewhere.  So Professor Sabe Sabesan in Townsville has started a model using community nurses to deliver mild or moderate intensity chemotherapy in small towns, and we’ve used those models in places like Walgett, in places like Cobar, to improve access and hopefully bring down mortality rates.

But in this sub-speciality, in medical oncology, there’s also a lot fewer adjunctive staff, so Allied Health staff or nurse coordination, and as a result, the buck stops with you a lot more.  In the city, I know I could just rely on the colon cancer coordinator to manage all the things that my patient needed to do prior to them coming in to seeing me in clinic for their first review.  Out here, it was me triaging the patients, it was me organising all of those tests and making sure that they’d got to Dubbo and the right place and got to the right CT Scanner and the MRI scanner and come here.  So there is that problem-solving issue, which is a bit more hands-on out here.

MIC CAVAZZINI:               Going back to your experience as a trainee –how often would you or your supervisor need to refer to other sub-specialists outside of Dubbo?

JOEL RILEY:         So while I was here as the STP trainee it was a slightly different to the current model. I was here as a Fellow, as a third-year trainee, and I would fly up by myself to Dubbo on the Monday and the Tuesday, and I’d have my supervisor on the phone.  So it was slightly different to what it is now, where I’m here full-time, and the STP trainees come through with someone just down the corridor. 

So as a result, I found myself referring a lot to my supervisor in Sydney, and I would call him a couple of times a day for help.  In terms of the amount of times I needed to refer outside for different subspecialty cover, probably twice or three times a day, and it would usually be for the high-specialty surgical opinions—so neurosurgery, upper gastrointestinal surgery—mainly because in cancer, there’s a lot of need for that sort of subspecialty care, and realistically, we’re never going to have a neurosurgeon in Dubbo.  We just couldn’t maintain the numbers of patients going through.

But what that does allow is that you do create relationships with those subspecialists, and even as a trainee, I found myself being known to a lot of the other subspecialists in Sydney, which is helpful both ways in that it does improve my ability to refer, and people would go out of their way to, you know, help me out, to give me education about what sort of things I needed to do before sending people down, and what sort of patients they were looking out for, and what sort of things that they would do particular operations for.  So I did actually find it quite helpful being the STP trainee from Dubbo in gaining those sorts of mentorships with specialties outside of my own.

MIC CAVAZZINI:               Dubbo hospital now has many opportunities for trainees. There’s a general medicine registrar, and the consultants are happy to support rotations out for subspecialty training. There’s a 6 month renal medicine AT position that is paired with Royal Prince Alfred and Liverpool Hospitals. The oncology AT is now a largely based in Dubbo, and in the works are respiratory and endocrine positions too.

Basic trainees from RPA make rotations out there both at the start and at the end of their three years, and the pipeline is about to get even more cohesive. Dubbo will soon have a postgraduate medical program for 96 medical students based entirely in the country. This is supported by the University of Sydney Medical School, and James Collett says they would welcome interest from academic clinicians. I asked him and Joel Riley what they like about living in the country, and what strategy would retain staff for the long-term.

JAMES COLLETT:               We do encourage them to hang around as much as possible, not only cos they do weekends here, but—I did a lot of terms as a trainee at different hospitals in rural and remote areas, and I really think it’s better when you stay in the area, but that’s’ from someone without kids, who’s married, but, you know, doesn’t have things tying me down.

JOEL RILEY:         I agree that trying to live in the place, it gives you a much better idea of what the place is like, but whether you’re partner enjoys being in the country is really important, probably the number 1, I reckon, the number 1 determinant whether people stay is can their partner enjoy living in Dubbo.  A lot of people’s partners have jobs that they can’t – that aren’t portable.  I think James and I are both lucky in that we’ve married into Allied Health, so our wives are both physiotherapists.

MIC CAVAZZINI:               If there’s one messages from this podcast….

JOEL RILEY:         Yeah.  And there are differences in the culture which are hard to communicate, but I’ll tell a small anecdote as an example, which is that my wife was thinking about doing some part-time work in physiotherapy, and so she called up the local physio department and asked if she could come in and visit, and they put on a morning tea for her, and just – they brought her in for a tour and put on a morning tea to say, hey, welcome, thanks, it’s really nice to see you, and imagine that happening in a metropolitan hospital.  I mean, can you imagine?

JAMES COLLETT:                               And, yeah, it’s six hours from Sydney, but Dubbos’ very accessible.  There’s five flights a day to Sydney.  You know, it’s always – I always say, you know, variety is good when you’re training, seeing, getting different perspectives, because you might come and go, actually, I’m a better person when I’m not in Sydney, but you’ve got to try it, and I think training is – you know, we talk about training, everyone focuses on your training for medicine, but you’re also training to live the best life you can, and so take advantage of the opportunity to go and live somewhere else and train to do that.  You know, I don’t think there’s anything wrong with going, well, let’s use this to see what it is like living somewhere else.  Yeah, you might hate it, but then you know.  It’s always good to try, and you might love it, and it might be better, which is what I found.

FLORIAN HONEYBALL:   On a personal level, I didn’t really appreciate what it was like living in a country town until I moved here, and I’ve all of a sudden, the whole commuting for 40 minutes each way and the city traffic and having to deal with the stressors of big-city life, versus having a 600,000 dollars with five bedrooms, a pool, a chicken run, which is five minutes from work and where my wife, who is also a doctor, can work in the same hospital, it’s just been amazing.  It’s really improved my quality of life substantially, and, you know, it’s an extra hour and a-half where I can do other things with my life.  So whether that’s supervising the medical students, doing some research with our advanced trainees or our registrars or doing some of my own stuff. Or my family, you know, so if I want to go home at 5.30 and cuddle my son, I can do that.

MIC CAVAZZINI:               Yeah, maybe final reflections on what you like about the community here.  I mean, I spent my early childhood on a cotton farm out near Trangie, and it was an incredible place to grow up, but there weren’t many cappuccinos to be found in Dubbo then. My dad would call it “the Paris of the Central West”.

FLORIAN HONEYBALL:   With huge slatherings of irony, of course.

MIC CAVAZZINI:               Well, that’s becoming less ironic every day, right?

FLORIAN HONEYBALL:                   Yeah.  Look, I think most rural communities are becoming much more metropolitan.  Dubbo has started to grow its agribusiness sector, and the hospital’s expanded, and I think with that, with the slightly higher disposable income has come a lot of more interesting cafes, and the art gallery’s opened up, and we have a relatively new cultural centre.  I actually find myself doing a lot more cultural activities than I used to when I was living in Camperdown in Sydney or Bondi, mainly because if the symphony’s in town, they’re here for this one night this year, I’ve got to go.  If the opera’s in town, they’re here for this one night, I’ve got to go.  If Bell Shakespeare’s here, I’ve got to go, so I go, and so I’m at the cultural centre once a month or more often, whereas I barely ever went out and did those cultural things in Sydney. So I’m actually findings myself to be more of a cultural snob now than I used to be when I was in the metropolitan setting. 

So these towns are changing, but I think also there’s a higher reward in that I find that all of my patients, even when I was trainee, really admired and respected the fact that I was coming here, even if it was two days a week in my STP training, and there is a loss of anonymity being in a rural community, but with that comes a greater sense of responsibility both ways.  So you are responsible for your community, but also the community feels responsible for you.  So I find that people are much more accommodating to what I suggest they do, and there is a lot of pride that there is an oncology service in this town now.

And when I came, there was a large community push to make sure that there was appropriate investigative services available for the new service that was coming with my employment, and so 46,000 signed a petition to get our new Western Cancer Centre, and it really does demonstrate the community pride and the community drive and that accountability.  So on a personal level, I’m so thankful that I was given that opportunity, and I wasn’t just blinded into staying in Sydney for another big-city job.

MIC CAVAZZINI:               Yeah, and that’s a good point because, again, one of those stereotypes is, “Well, it’s not going to look good on my CV if I’m training in a rural town instead of a big-shot research hospital” or whatever.  Do you think that’s true, or do you think you’re actually likely to get regarded as more competent?

FLORIAN HONEYBALL:   Well, look, I think the stigma is there, you know.  I’m not going to lie, I think that there is a bit of a stigma.  For someone who’s short-sighted, maybe that is a problem that, “if I start working in a rural community, then maybe I won’t get a job back”. But then if you stick around, do a few years, get a few years under your belt, all of a sudden, you’re very valuable.  You’re a clinician with significant experience.  The experience that I’ve been able to get out here, and I’ve been given all these managerial roles as well, all of a sudden has made me a bit more valuable if I did want to move back to a metropolitan area, and recently I was headhunted a large regional centre, cancer centre, and, look, the reality is that nowadays in large cities, at least in my subspecialty, in Sydney and Melbourne, you can be sitting around waiting for a job for years, whereas I was able to get a full-time staff specialist job in a town where my skills were really really sought after, and I’ve been able to keep going with my own health services research and present it internationally whilst being able to professionally really grow, not just in my clinical medicine, but also in my management and my management skills.

MIC CAVAZZINI:               Yeah, you’re talking about management, and you were even asked to advise on how the hospital’s going to spend it’s 250 million dollars.

FLORIAN HONEYBALL:   Yes, so I’m a part of the executive committee, which decides how the cancer centre and also other parts of the development will go ahead in the Dubbo Health Service.  I sit on the District Clinical Council, was the chair of Cancer Services for Western New South Wales, so that means that I sit with the CEO and the other heads of department from around the local health district and decide on how to expand and provide better services for our community. And I’m 36, five years into the job.  There’s no way I’d be able to get those sorts of experiences biding my time with a PhD sitting around in a 0.2 job in a job in a private hospital.  

MIC CAVAZZINI: That was Florian Honeyball ending this episode of Pomegranate Health. Thanks also to James Collett and Joel Riley for their contribution. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians.

There’s information on our website about the Specialist Training Program and an eLearning module about how to make the most of tele-supervision. That’s at racp.edu.au/podcast. Also in the works are some tools to help rural trainees prepare for clinical exams. One big help already available is the College Learning Series- these video recorded lectures are aligned to the Basic Training curriculum for adult medicine, and paediatrics is also now being rolled out. Just search for online Learning Resources @ RACP in your browser.

Please share this podcast with your trainee friends, or any colleagues that could do with a tree-Change. You can subscribe to Pomegranate Health via any podcasting app, and there’s even an mailing list for the late-adopters.

I’m Mic Cavazzini. Thanks for listening.



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21 Apr 2024
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